Transfusions—The Key to Survival?
IN 1941 Dr. John S. Lundy set a standard for blood transfusions. Apparently without any clinical evidence to back him up, he said that if a patient’s hemoglobin, the oxygen-carrying component of blood, goes down to a level of ten grams or less for every deciliter of blood, then the patient needs a transfusion. Thereafter that number became a standard for doctors.
This ten-gram standard has been challenged for nearly 30 years. In 1988 The Journal of the American Medical Association flatly stated that the evidence does not support the guideline. Anesthesiologist Howard L. Zauder says it is “cloaked in tradition, shrouded in obscurity, and unsubstantiated by clinical or experimental evidence.” Others simply call it a myth.
Despite all this vigorous debunking, the myth is still widely revered as a sound guideline. To many anesthesiologists and other doctors, a hemoglobin level of below ten is a trigger for transfusion to correct the anemia. It’s virtually automatic.
No doubt, that helps account for the vast overuse of blood and blood products today. Dr. Theresa L. Crenshaw, who served on the Presidential Commission on the Human Immunodeficiency Virus Epidemic, estimates that in the United States alone, some two million unnecessary transfusions are administered every year and that about half of all transfusions of banked blood could be avoided. Japan’s Health and Welfare Ministry decried “the indiscriminate use of transfusions” in Japan, as well as the “blind belief in their efficacy.”
The problem with trying to correct anemia with a blood transfusion is that the transfusion can be more deadly than the anemia. Jehovah’s Witnesses, who refuse blood transfusions primarily on religious grounds, have helped to prove the point.
You may have seen newspaper headlines reporting that one of Jehovah’s Witnesses died because of refusing a blood transfusion. Sadly, such reports rarely tell the whole story. Frequently, it is the doctor’s refusal to operate, or to operate soon enough, that spells death for the Witness. Some surgeons refuse to operate without freedom to transfuse if the hemoglobin level drops below ten. However, many surgeons have successfully operated on Witnesses with hemoglobin levels of five, two, and even less. Says surgeon Richard K. Spence: “What I’ve found with the Witnesses is that the lower hemoglobin does not relate to mortality at all.”
A Wealth of Alternatives
‘Blood or death.’ That is the way some doctors describe the alternatives facing a Witness patient. Yet, in reality, there are many alternatives to blood transfusion. Jehovah’s Witnesses are not interested in dying. They are interested in alternative treatments. Because the Bible forbids the ingesting of blood, they simply don’t consider blood transfusions an alternative.
In June 1988, the Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic suggested that all patients be given just what the Witnesses have been requesting for years, namely: “Informed consent for transfusion of blood or its components should include an explanation of the risks involved . . . and information about appropriate alternatives to homologous blood transfusion therapy.”
In other words, patients should be given a choice. One such choice is a type of autologous transfusion. The patient’s own blood is salvaged during the operation and recirculated back into the patient’s veins. Where such a process is simply an extension of the patient’s own circulatory system, it is quite acceptable to most Witnesses. Surgeons also stress the value of increasing the patient’s blood volume with nonblood expanders and letting the body replenish its own red cells. Such techniques have been used in place of transfusions without increasing mortality. In fact, they can improve safety.
A promising drug called recombinant erythropoietin has recently been approved for limited use. It speeds up the body’s own production of red blood cells, in effect helping a person to make more of his own blood.
Scientists are still searching for an effective substitute for blood that imitates its remarkable oxygen-carrying capacity. In the United States, the makers of such substitutes find it hard to get approval for their products. Yet, as one such maker objected: “If you thought about bringing blood to the FDA [Food and Drug Administration] to be approved, you wouldn’t have a prayer of ever getting it tested it’s so toxic.” Still, hopes are high that an effective chemical will be found that will be approved as an oxygen-carrying substitute for blood.
So there are choices. Those mentioned here are but a few of those available. As Dr. Horace Herbsman, a professor of clinical surgery, wrote in the journal Emergency Medicine: “It’s . . . quite clear that we do have alternatives to blood replacement. Indeed, perhaps our experience with Jehovah’s Witnesses might be interpreted to mean that we do not need to rely on blood transfusions, with all their potential complications, as much as we once thought.” Of course, none of this is really new. As The American Surgeon noted: “The fact that major operations can be safely performed without blood transfusions has been amply documented in the past 25 years.”
But if blood is dangerous, and there are safe alternatives to its use, then why are millions of people transfused unnecessarily—many of them without knowing it, others actually against their will? The report of the presidential commission on AIDS notes in part the failure to educate doctors and hospitals about the alternatives. It blames another factor too: “Some regional blood centers have been hesitant to promote strategies that minimize the use of transfusion therapies, since their operating income is derived from the sale of blood and blood products.”
In other words: Selling blood is big business.